by Linda Homan, RN, CIC

The role of environmental hygiene in infection prevention is rapidly gaining recognition as a result of a growing body of research that links infections with the patient environment. As indicated in Table 1, pathogens such as Clostridium difficile, MRSA, and VRE can survive on environmental surfaces for extended periods of time and can also be very difficult to eliminate. Several studies have demonstrated that these and other pathogens are readily transmitted between healthcare workers’ hands and the patient environment.¹ Compounding this issue, it has been documented that patient rooms are frequently not cleaned well enough to remove these pathogens. ^2-4 Further studies have demonstrated that patients admitted to rooms previously occupied by patients with these pathogens are at increased risk of acquiring the pathogen. ^5-

Table 1. Pathogen survival on environmental surfaces

Though it’s understood where pathogens live and how they get spread in patient rooms, any solution needs to understand and address the real world operational challenges that environmental services departments face every day. Staffing the environmental services department is an ongoing challenge. The work is physically demanding and not always appreciated. Additionally, environmental services employees often have English as a second language, which limits the effectiveness of communication materials. High staff turnover is often seen in this department which makes maintaining consistent cleaning standards difficult. Though it requires a concerted effort, building an effective environmental services department can be achieved through a program that includes training and education, processes and tools to consistently deliver disinfectant concentration, objective outcome monitoring, and sustainable solutions.

A holistic, programmatic approach that manages the following key components of environmental hygiene, will deliver improved critical cleaning outcomes.

• Training and education on best practices;
• Consistent delivery of correct disinfectant concentration;
• Standardized cleaning processes to consistently disinfect high touch objects;
• Infection control practices to prevent cross contamination;
• Improved efficiency to clean thoroughly while meeting room turnover expectations;
• Ergonomic tools and practices to prevent injury;
• Objective metrics to measure program effectiveness.

Making Training More Effective

High touch objects, or objects that are touched often by healthcare workers and patients and potentially contaminated with pathogens, range from door handles to tray tables (See Table 2). Unfortunately, despite the fact that that these surfaces are the most frequently touched, cleaning of them is inconsistent at best. In one study that evaluated the thoroughness of environmental cleaning in three hospitals, only 47 percent of high touch objects were found to have been cleaned. ⁸

Table 2. High Touch Object Examples

                        Patient Room                                    

• Door Handles   
• Call Button
• Telephone
• Bed Rail
• Tray Table
• Beside Table

 Patient Bathroom

• Faucet Handles
• Toilet Flush
• Toilet Seat
• Toilet Handrail
• Bed Pan Washer
• Bathroom Door Handle

Repeating this study in a larger set of hospitals confirmed the original findings that cleaning was suboptimal with an average of 49 percent of high touch objects cleaned in patient rooms. ⁹ Hayden et al used covert visual observation of cleaning practice in ICU patient rooms and found that an average of 41 percent of high touch objects were cleaned. ¹⁰ This research underscores the need for improvement in environmental services training and education to teach proper cleaning of high touch objects (HTOs).

Central to training are important infection control practices such as performing hand hygiene between “dirty” and “clean” activities, moving from clean to dirty areas when cleaning and separation of clean and dirty items to prevent the spread of pathogens. Environmental cleaning is a physically demanding job, and best practices for efficiency and ergonomics should also be emphasized. New carts and tools that are specifically designed to prevent cross contamination and make cleaning more effective are available and should be considered. Though they may seem basic, tools such as microfiber mops and cloths can have a big impact on the efficiency, thoroughness and speed with which housekeeping staff are able to clean rooms.

Consistent Delivery of Disinfectant Concentration

One of the basics of infection prevention is that disinfection requires that the appropriate concentration of chemical be applied to surfaces. However, many current environmental service programs do not control the product concentration, water pressure, product delivery method or the application tools and process needed for the disinfectant to be effective. This is apparent when looking at the color variations between buckets of disinfectant in use in patient care areas, which is indicative of the variations in disinfectant concentration. Cotton cloths and string mops are still widely used which can further dilute the disinfectant concentration delivered to surfaces because the quaternary ammonium compounds can bind with the cotton fibers. ¹¹ To address these issues, environmental services should consider automated dispensing systems and appropriate tools that help ensure the disinfectants being used by housekeeping staff are consistent in concentration.

Sustainable Solutions

Water and chemical waste are considered a necessary side effect of environmental cleaning. Many hospitals use buckets filled with disinfectant solution that must be discarded after a pre-determined number of uses to prevent cross contamination. This process is inefficient, time-consuming and wastes product and water. A more efficient process is to saturate microfiber cloths and mops in bucket of a pre-measured disinfectant solution. This eliminates waste of both water and disinfectants.

Objective Outcome Monitoring

Measuring cleanliness in a consistent manner is critical to improving environmental hygiene. Current quality metrics for environmental services are often subjective, based on the appearance and perception of cleanliness such as shiny floors. When methods are introduced to monitor the effectiveness of cleaning, they are typically based on direct observation and/or environmental culturing but both of these methods have limitations. Direct observation is often subjective and staff performance can be influenced when the staff is aware they are being monitored. Environmental culturing is costly and must be completed immediately after cleaning to in order to accurately measure cleaning effectiveness. In addition, the opportunity to give immediate performance feedback to staff has passed by the time the culture results are available, making it less useful as a training tool. To resolve these limitations, environmental services managers and infection preventionists can use a variety of monitoring tools ranging from ATP swabs to substances applied to the surface that show whether it has been cleaned or not. Substances such as DAZO, a fluorescent gel marking solution that glows under black light, have been developed by experts such as Dr. Philip Carling, director of infectious diseases and epidemiology at Caritas Carney Hospital in Boston, as a mechanism for evaluating cleaning. Though not visible to the naked eye, DAZO allows auditors to see which surfaces have been cleaned to better train the environmental services staff.

A Path Forward

Studies published by Dr. Carling and others have shown that decreased environmental contamination and acquisition of pathogens can be achieved with a programmatic approach to environmental hygiene. The programmatic approach used by Dr. Carling included education paired with a unique monitoring tool that uses a transparent gel which becomes visible only under UV light. It dries rapidly and resists abrasion, yet is readily and thoroughly removed by all disinfectants. The basic research method used is as follows:

1. Baseline environmental cleaning of high touch objects was evaluated using the transparent gel.
2. An intervention of training and objective performance feedback focused on cleaning of high touch objects was conducted.
3. Following the intervention, environmental cleaning effectiveness was again measured using the transparent gel.

In all of the studies in which this method was used, the thoroughness of environmental cleaning was improved. ^{2, 12-14} Studies using other methods of measuring improvement in environmental cleaning noted similar improvements with a programmatic approach. In the observational study by Hayden, thoroughness of environmental cleaning improved from 41 percent to 84 percent following interventions. ⁹ In a culture-based study, Eckstein found a decrease in VRE environmental contamination from 71 percent to 23 percent and C. difficile environmental contamination from 71 percent to 11 percent when routine cleaning was replaced with trained research staff cleaning. ¹⁵

Evolving Guidelines, Recommendations and Regulations

Guidelines, recommendations and regulations by state, national and global agencies are continually evolving but echo the best practices such as monitoring performance and creating a standardized method for measuring and reporting compliance, discussed above. Key recent changes to note, include the 2009, Department of Health and Human Services (DHHS) and the State of California guidance related to environmental hygiene, which stated, “Standardized methods (i.e., performance methods) that are feasible, valid, and reliable for measuring and reporting compliance with …, environmental cleaning practices in order to prevent infection.” ^16,17

In conjunction with healthcare experts, Ecolab designed its Encompass™ program, a comprehensive program that helps hospitals improve their environmental hygiene performance. Pilot studies conducted to evaluate the key components of the program showed significant results including:

• The effectiveness of environmental cleaning as measured before and after intervention as the percentage of high touch objects that were cleaned was improved by 32 percent. Environmental cultures were taken and a total aerobic plate count was used to validate the cleaning effectiveness as measured by DAZO™.  Total aerobic plate counts read as 0 CFU significantly improved by 45 percent post-pilot intervention.
• Discharge cleaning time was reduced by 15 percent.
• Water usage was reduced by as much as 86 percent.
• Chemical usage on floors and surfaces was reduced by as much as 80 percent and 74 percent respectively.

For More Information

• Department of Health and Human Services. <I>Action Plan to Prevent Healthcare-Associated Infections<I>. http://www.hhs.gov/ophs/initiatives/hai/infection.html
• State of California Bill- http://www.cdph.ca.gov/services/boards/Documents/SB158chaptered09_25_08.pdf
• Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008- http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf
• WHO Guidelines for Hand Hygiene in Health Care, 2009- http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf

References

1. WHO Guidelines for Hand Hygiene in Health Care. Geneva, World Health Organization, 2009.
2. Goodman ER, Platt R, Bass R, Onderdonk AB, Yokoe DS, Huang SS. Impact of an environmental cleaning intervention on the presence of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci on surfaces in intensive care unit rooms. Infect Control Hosp Epidemiol. 2008 Jul;29(7):593-9.
3. Carling PC, Von Beheren S, Kim P, Woods C; Healthcare Environmental Hygiene Study Group. Intensive care unit environmental cleaning; an evaluation in sixteen hospitals using a novel assessment tool. J Hosp Infect. 200 Jan;68(1):39-44.
4. Boyce JM, Havill NL, Lipka A, Havill H, Rizvani R. Variations in hospital daily cleaning practices. Infect Control Hosp Epidemiol. 2010 Jan;31(1):99-101.
5. Huang SS, Datta R, Platt R. Risk of acquiring antibiotic-resistant bacteria from prior room occupants. Arch Intern Med. 2006 Oct 9;166(18):1945-51.
6. Hardy KJ, Oppenheim BA, Gossain S, Gao F, Hawkey PM. A study of the relationship between environmental contamination with methicillin-resistant Staphylococcus arueus (MRSA) and patients’ acquisition of MRSA. Infect Control Hosp Epidemiol.2006 Feb;27(2):127-32.
7. Drees M, Snydman DR, Schmid CH, Barefoot L, Hansjosten K, Vue PM, Cronin M, Nasraway SA, Golan Y. Prior environmental contamination increases the risk of acquisition of vancomycin-resistant entercocci. Clin Infect Dis. 2008 Mar 1;46(5):678-85.
8. Carling PC, Briggs J, Hylander D, Perkins J. An evaluation of patient area cleaning in 3 hospitals using a novel targeting methodology. Am J Infect Control. 2006 Oct;34(8):513-9.
9. Carling PC, Parry MF, Von Beheren S, Kim P, Woods C; Healthcare Environmental Hygiene Group. Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals. Infect Control Hosp Epidemiol. 2008 Jan:29(1):1-7.
10. Hayden MK, Bonten MJ, Blom DW, Lyle EA, van de Vijver DA, Weinstein RA. Reduction in acquisition of vancomycin-resistant enterococcus after enforcement of routine environmental cleaning measures. Clin Infect Dis. 2006 Jun 1;42(11):1552-60.
11. L Grieme, K Thompson, HL Carbone. Evaluation of Quat Absorption and Efficacy of Cleaning Cloths, APIC 2009, poster.
12. Carling PC, Briggs JL, Perkins J, Highlander D. Improved cleaning of patient rooms using a new targeting method. Clin Infect Dis. 2006 Feb 1;42(3):385-8.
13. Carling PC, Parry MM, Rupp ME, Po JL, Dick B, Von Beheren S; Healthcare Environmental Hygiene Study Group. Improving cleaning of the environment surrounding patients in 36 acute care hospitals. Infect Control Hosp Epidemiol. 2008 Nov;29(11):1035-41.
14. Po JL, Burke R, Sulis C, Carling PC. <I>Dangerous cows: an analysis of disinfection cleaning of computer keyboards on wheels. Am J Infect Control. 2009 Nov;37(9):778-80.
15. Eckstein BC, Adams DA, Eckstein EC, Rao A, Sethi AK, Yadavalli GK, Donskey CJ. Reduction of Clostridium difficile and vancomycin-resistant enterococcus contamination of environmental surfaces after an intervention to improve cleaning methods. BMC Infec Dis. 2007 Jun 21;7:61.
16. Department of Health and Human Services. Action Plan to Prevent Healthcare-Associated Infections. Agency for Healthcare Research and Quality; Office of the Assistant Secretary for Public Affairs; Office of the Assistant Secretary for Planning and Evaluation; Centers for Disease Control and Prevention; Centers for Medicare and Medicaid Services; Food and Drug Administration; National Insitutes of Health; Office of the National Coordinator for Health Information Technology; Office of Public Health and Science. 2009 Jun 22.
17. State of California. Senate Bill 158, Chapter 294. An act to amend Sections 1288.5 and 1288.8 of, and to add Sections 1279.6, 1279.7, 1288.45 and 1288.95 to, the Health and Safety Code, relating to health facilities.

Linda Homan, BSN, CIC is manager of clinical and professional services for Ecolab Healthcare. Ms. Homan is CBIC-certified in infection control and has been active in the field for more than 20 years. She has held leadership positions in the Association for Professionals in Infection Control (APIC) including president and vice president of the Minnesota chapter and board member of the National APIC Research Council (formerly the APIC Research Foundation).